Healthcare Provider Details

I. General information

NPI: 1184799298
Provider Name (Legal Business Name): UPPER VALLEY ORTHOPEDICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E MAIN ST
REXBURG ID
83440-2015
US

IV. Provider business mailing address

360 E MAIN ST
REXBURG ID
83440-2015
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9550
  • Fax: 208-356-8023
Mailing address:
  • Phone: 208-356-9550
  • Fax: 208-356-8023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM5158
License Number StateID

VIII. Authorized Official

Name: DR. MICHAEL J LARSON
Title or Position: OWNER
Credential: MD
Phone: 208-356-9550